Provider Demographics
NPI:1013418045
Name:FESHOLD, SUSIE A (OTR)
Entity Type:Individual
Prefix:MRS
First Name:SUSIE
Middle Name:A
Last Name:FESHOLD
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:SUSIE
Other - Middle Name:
Other - Last Name:HALEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4800 W ARKANSAS LN
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76016-1909
Mailing Address - Country:US
Mailing Address - Phone:682-867-8345
Mailing Address - Fax:
Practice Address - Street 1:1000 W CROSBY RD STE 136
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-6904
Practice Address - Country:US
Practice Address - Phone:972-237-0101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-25
Last Update Date:2018-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108185225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX225X00000XMedicaid